A clinical research project evaluating a newly structured, 4-session treatment intervention for anxiety

through a multisite clinical trial

By:

Everett McGuintyAdjunct Professor, Faculty of Education, UWO

John NelsonPsychological Associate, BCBA

David ArmstrongChief Psychologist, UCDSB

Research Team

• David Armstrong, Chief Psychologist Eric Crowther, MSW

• John Nelson, Psych., Associate, BCBA Dina Bednar, MA, RP

• Alain Carlson, Ph.D. (in progress) Stephanie Sheeler, BSW

• Danielle Morrow, MA, RP Kaitlyn Yarlasky, MA, RP

• Brian Bird, C. Psych (in progress) Anne-Marie Carrier, MA

• Joana Silva, C. Psych (Portugal) Mirisse Foroughe, C. Psych

BTAS

Overview

• 1. Introduction and Brief Services

• 2. Brief Task Acquisition Scale

• 3. Best Practices in Brief Services

• 4. Innovative Moments (Portugal)

• 5. Results of 2 pilot studies: Transitional-aged youth

• 6. The Treatment Protocol: A multi-site clinical trial

BTAS

Brief Services• single session, walk-in, and 1 to 3 sessions

• assessing outcome measurement: change

• Who? What? When? Why? (CLIENT)

• historical methods of measuring change, BS

• a newly suggested paradigm shift

BTAS

The Myth• counselling (BAS) vs psychotherapy

• just supportive counselling built on strengths

• offering of tips and ideas

• psycho-education focused

• little change is possible due to time factor

• results not comparable to long-term

BTAS

Brief Task Acquisition Scale

• has a defined structure and process

• more than tips, ideas, and psychoeducation

• great change is possible due to time factor

• relatively new psychotherapy modality

BTAS

Current context

• practitioners with experience delivering evidence-

based (e.g. CBT, behavioural, solution focused) and

popular (e.g. narrative therapy, emotion-focused)

interventions were invited to discuss ‘common factors’

of the intervention components in only 4 sessions

• candidate components were identified as ‘tasks’ or

goals common to these approaches, and potentially

helpful in short-term intervention

• How much did the symptom reduce?

- symptom reduction measurement

- pre and post session evaluation

VS

How did the symptom reduce?

- process of change client experienced

- within session evaluation (and across)

Presentation Title Here

Structure and Process Differences

long- te rm{1_ 2_ 3}_ _5 6___ __ 10 11________15

s hor t- te rm _1_ _2_ _3_

s ingle s e s s ion

_1_

BTAS

BTAS

BTAS

Cognitive Behavioral Therapy In terms of defining and assessing the problem, CBT theorists and clinicians stress the importance of developing and maintaining a strong therapeutic relationship with the client from the first point of contact, and developing realistic goals for short-term work. While clients are instructed about the cognitive model, and educated about their problems, it is essential to work on reducing their distress. Clinicians also set in motion a process of socializing clients into therapy by instructing them about homework and its importance, by setting an agenda, by eliciting their reactions to the therapeutic process and by making sure that they understand what the clinician is thinking and proposing.

Solution Focused Brief TherapyThe first stage of Solution Focused Brief Therapy work involves three main objectives: (1) inquiring about pre-session change, (2) discovering the strengths and resources of the client; and (3) defining the ‘problem’ and what the client wants different as a result of coming to therapy (solution and attainable goal). Main interventions include looking for previous solutions, looking for exceptions, questions instead of directives or interpretations, present and future-focused questions, assigning tasks, and compliments. Specific interventions consist of the ‘Miracle Question’, ‘Solution-Focused Goals’, and ‘Scaling’.

Narrative TherapyThe client-clinician relationship may explore strengths and resources embedded within rich stories past, present, and even future. Deconstructing the problem begins by naming it, exploring its impact upon the areas of the client’s life. Problems are identified, objectified, personified, and externalized, first through the use of language, and often later, in clinician-generated metaphors. Aresulting person-and-problem relationship is described and viewed as separate entities, impacting upon the client’s view of self, others, and life. The relationship begins to explore exceptions or unique outcomes that subvert the existing problem saturated story, through the narratives; and then taking position against the problem.

Emotion Focused Therapy While an assumption of Emotion Focused Therapy is that emotions are fundamentally adaptive in human survival and well-being, emotional processes can become problematic for people as a result of past traumas or even ongoing misattunement between the person’s emotional needs and what is available in their environment, leading to a pattern of emotion avoidance. This avoidance results in increasing pain and distress, as well as interfering with the individual’s ability to identify their needs and goals.

BTAS

CBT

SFBT

NT

EFT

BTAS

CBT

SFBT

NT

EFT

BTAS

Stage 1: Defining and assessing the problem1. Name the problem and develop a common understanding

2. Identify influences of problem within areas of life

3. Explore the severity, or size, of the problem

4. Evaluate preferences, commitments, and motivations for change

5. Assess strengths and resources as they relate to problem

BTAS

Stage 2: Shift the problem 6. Brief review and assess readiness/motivation to begin change

7. Explore experiences of emotion, beliefs, and actions as they relate to the problem

8. Further develop the change that is already happening

9. Develop positive action oriented plan and signs that it occurs in other aspects of life

10. Encourage smaller, manageable steps to maximize the likelihood of success based upon abilities

BTAS

Stage 3: Change the problem 11. Review understanding of problem and progress since last session

12. Pay attention to and reflect what is working and do more of that

13. Assign tasks that clarify and build on plan, goals, and exceptions

14. Make small adjustments based on what the client is already doing, thinking, and feeling

15. Identify expected change between session, new change areas, and build independent support after ending

BTAS

Stage 4: Generalize and maintain the change 16. Develop plan to maintain the change, while including the support from others to sustain this change

17. Expand the change to include other areas

18. Anticipate and plan for obstacles to continued success, and when getting off track

19. Evaluate to what extent the tasks, stages, and change resulted in the goal for therapy

20. Discuss ending and possible need for other services *

BTAS

BTAS

4

3

1

2

0

very much

moderately

not at all

Tasks Client Clinician C/C

Stage 1

1

23

45

Total

Stage 2

678910

Total

Stage 31112131415

Total

Stage 41617181920

Total

TOTAL

Process Evaluation

0

1

2

3

4

Session 1 Session 2 Session 3 Session 4

Task

Co

mp

leti

on

ALLISON: SESSION AVERAGE

0

1

2

3

4

Session 1 Session 2 Session 3 Session 4

Task

Co

mp

leti

on

MALCOLM: SESSION AVERAGE

0

1

2

3

4

Session 1 Session 2 Session 3 Session 4

Task

Co

mp

leti

on

ETHAN: SESSION AVERAGE

0

1

2

3

4

Session 1 Session 2 Session 3 Session 4

Task

Co

mp

leti

on

ZENNA: SESSION AVERAGE

CONGRUENCE/VARIANCE

Internalizing

VS

Externalizing

BTAS Summary• one size doesn’t fit all (short vs long-term)

• unifying structure and process of change

• 20 tasks representing 5 therapy schools

• greater treatment integrity: common structure

• time-sensitive information for client-clinician

• save resources due to duplication of services

BTAS

• clients contribute directly to outcome

• psychotherapy is more transparent than ever

• offers clinician and agency PD information

• introduces a new language of change

• provides ‘profiles’ on specific problems

• serves as treatment monitoring tool

• relies upon continuous evaluation/feedback

• affirming change = increasing motivation BTAS

BEST PRACTICES IN BRIEF SERVICES

Evidence-based treatments

Large ES with EST in mixed clinical

samples research• In subjects presenting with CBT for generalized anxiety disorder, 11

studies contributed an effect size of 0.92 for clinically-representative studies (95% CI = 0.77-1.07), and depression scores also decreased 0.89 (0.70-1.07). Patients were allowed concurrent treatment such as medication. (Stewart & Chambless, 2009).

• Westbrook & Kirk (2005) examined effectiveness of 906 patients presenting at a free adult mental health clinic for various concerns. Mean number of sessions was 13.2 (SD = 5.7), in which therapists used a wide variety of counseling or treatment. When applying symptom measures regardless of presenting concern, BDI 0.67 and BAI 0.54. When examining only those records above clinical cut-offs, BDI 1.15 BAI 0.94. 0.54 was therefore used in this study to best match the current sampling techniques.

• Finally, Minami and colleagues (2007) report an unstandardized mean difference in BDI scores of 1.86 in a review of 29 psychotherapy outcome studies involving 1 387 participants with depression.

• Searched PsycINFO and the Cochrane Collaboration for outcome

studies, review papers, and meta-analyses from January 1990 to

January 2012.

• Keywords “intervention" OR "therapy" OR "outcomes" AND "child*"

OR "adolesc*" OR "family" AND "outcome*" OR "trial*". The search

was limited to English-language, peer-reviewed journal articles.

• Search strategies also included a thorough investigation of reference

lists in relevant review articles and personal communications with

authors of relevant studies.

• The inclusion criteria for the present meta-analysis were the

following:

– nature of treatment was limited to psychotherapy;

– treatment was delivered within 6 sessions, weeks, and hours;

– youth were 19 years of age and younger;

– youth were the clinical focus of treatment;

– there was sufficient information to calculate an effect size;

– outcome was measured in terms of change in psychological symptoms.

30

40

50

60

70

80

Pre PostBrief Services

Brief

Services

d=1.0

Building success:

Defiance / Opposition

OLS weighted regression predicting parent ratings

Triple P

Problem

Solving

Family

Relations

EMDR

Treatments

k = 6

Building success:

Anxiety / Mood

OLS weighted regression predicting clinician ratings

CBT

EMDR

Treatments

k = 6

#Treatments That Work for

Brief Children’s Services

• Three controlled trials indicating EMDR / imaginal exposure for traumatic stress

• Three controlled trials indicating exposure for specific phobias (OST)

• Two controlled trials indicting parent management training (PCIT/PPP) for child defiant behavior

• Two controlled trials note a number of interventions possibly efficacious for youth anger (anger mgmt, CBT, EMDR)

• Three clinical trials note promising practices of stress management / solution focused / cognitive-behavioural approaches for interlanizing problems

Innovative Moments

• Unique Outcome or Exceptions to the Problem

• 7 types of Innovative Moments

• Between session worksheet (BTW S1+S2)

• Examples of IMs for anxiety

• 800 transcripts coded

• Active priming of IMs in psychotherapy

Diagram of Work Between Sessions

Transitional-Aged Youth: Pilot Study

(4 Ontario Universities)

• To evaluate the size and nature of effects of a

proposed short-term treatment for anxiety

and stress difficulties

• This information will be used for the design of

subsequent clinical trials

Participants

• Eligibility

– Included students presenting concerns of stress and

anxiety at post-secondary counseling centers.

• Exclusion criteria

– Diagnosis of OCD, PTSD, PD, or other severe mental

illness

– Moderate to severe risk of self-harm or harm to

others

Session

#1

Session

#2

Session

#3

Evaluation

Wrap-up

Baseline

AssessmentEndpoint

Assessment

• Demographics

•STAI

•DASS

•STAI

•DASS

1. Includes Social Anxiety Disorder, Generalized Anxiety Disorder and Anxiety Disorder Not Otherwise Specified

2. Includes Major Depressive Disorder and Dysthymic Disorder

3. Includes Specific Phobia, Panic Disorder, Obsessive Compulsive Disorder, and Post-traumatic Stress Disorder

Diagnosed SuspectedEndorsing no

difficulties

General and social

anxiety1 14 (28%) 18 (36%) 18 (36%)

Depression and

Dysthymia2 11 (23.4%) 8 (17%) 28 (59.6%)

Other anxiety3 6 (12.2%) 12 (24.5%) 31 (63.3%)

Personality disorders 0 (0%) 1 (2%) 48 (98%)

Alcohol or substance use

disorders0 (0%) 2 (4.1%) 47 (95.9%)

Difference between baseline & endpoint

0

0.2

0.4

0.6

0.8

1

Depression

(n=48)

Anxiety

(n=48)

Stress

(n=48)

Trait Anxiety

(n=46)

p < 0.005

p < 0.005

p < 0.005

p < 0.005

30

40

50

60

70

80

Pre PostBrief Services

EMT

d=0.95

Equivalence to Treatment as Usual

• EMT proved as effective as typical intervention in an exploratory

analysis of control-group data

• Independent samples t-tests revealed no significant differences in

raw change scores (i.e., pre – post) for

• DASS-21 Depression [t(42) = .057, p = .96],

• DASS-21 Anxiety [t(42) = -1.069, p = .29],

• DASS-21 Stress [t(41) = -.56, p = .58], or

• STAI Trait Anxiety [t(40) =-.231, p = .818].

BTAS

The EMT Treatment Protocol

An overview of the structured,

4-session treatment intervention

BTAS

Development of EMT• a short-term treatment intervention for internalizing

behaviors: Externalizing Metaphors Therapy

• based upon an externalizing process, transforming of metaphoric imagery, and shifting underlying maladaptive emotional schemas

• two specific change processes: (1) externalizing of problems, (2) purposeful client-generated metaphor manipulation impacting upon underlying schemas

• treatment protocol based upon Narrative Therapy (externalizing and deconstruction) and Metaphor Therapy (metaphor transformation)

BTAS

• relevance for brief services and in its versatility for the clinical populations: (1) children and adolescents, (2) high functioning autism (3) adults with dual-diagnosis, and (4) adults in general.*

• EMT treatment protocol may be taught through a one-day training event lasting only 6 hours

• a 3-session model for anxiety and depression, offered individually (possibly group format, pilot)

• offers a model for clinically evaluating a new Brief Services model within transitional aged youth and CMH settings

BTAS

BTAS

EMT: Autism • explored the efficacy of both the literal and concrete

externalization aspects within Narrative Therapy, and the implementation of interactive metaphors as a combined psychotherapeutic approach for decreasing anxiety with high-functioning autism

• a change process is described which allows for concretizing affective states and experiences, and makes use of visual strengths of clients (HFA)

• Cashin - externalizing (2005); Ory – metaphors (2004); Nash - storage of image vs narrative (2002)

BTAS

BTAS

EMT: CMH • A Clinical Treatment Intervention for Dysphoria: Externalizing

Metaphors Therapy, Clinical Psychology & Psychotherapy (2013)

• - shortened version of treatment protocol (table)

• - structure of each session is outlined

• - training exercises for clinician in training

• - case study with Tommy & Kathleen, 3 sessions

• - literature review of Brief Services

BTAS

Session #1: Externalizing the problem

1. Strengths/resources with hopes, dreams and

wishes

2. Externalization introduced

3. Influence/impact of the problem on three domains

(sense of self, sense of others/relationship and sense

of life) and three aspects (thoughts, feelings and

actions)

4. Evaluation—posturing

5. Exercises: (a) strength/resources list compared to

(b) what the problem wants for client’s life list

BTAS

Session #2: Metaphor development

1. Externalizing concepts reviewed

2. Metaphor creation and development

3. Metaphor exploration on four domains

(relationship between self and problem, sense of self,

sense of others/relationship and sense of life) in

reference to the three aspects (thoughts, feelings and

actions)

4. Metaphor’s view of hopes, dreams and wishes

5. Intervention choice: relaxation, cognitive

restructuring and problem solving

BTAS

Session #3: Metaphor shift

1. Externalizing concepts reviewed

2. Adjust/shift existing metaphor or create new

metaphor and adjust/shift in four ways: (a) explore

metaphor to see how it has evolved or changed,

reflecting this back to client for meaning; (b) use

client strengths to see if they changed metaphor; (c)

use client examples of success to see if metaphor

changed; (d) use the exercises taught to see if

metaphor has changed

BTAS

Session #3: Metaphor shift (continued)

3. Metaphor exploration on four domains

(relationship between self and problem, sense of self,

sense of others/relationship and sense of life) in

reference to the three aspects (thoughts, feelings and

actions)

4. Intervention choice: relaxation, cognitive

restructuring and problem solving

5. Create a plan of action

BTAS

Session #4: Maintenance and Generalization

1. Client and guardian review externalizing language

clinician takes outsider witness position

2. Review the 7 IMs since treatment group began

3. Expand upon domains impacted by anxiety into

other areas of life (Generalization)

4. Maintenance plan – client directed to use same

metaphor in other domains of life, affirming an active

plan to further shift metaphor after therapy ends

BTAS

Treatment Group: Pilot Study

• MASC2 pre-measurement

Session 1. Externalize the problem

Session 2. Create metaphor

Session 3. Shift metaphor

Session 4. Maintain and generalize change

• MASC2 post-measurement

* IMs between session exercises

* International Journal of Group Psychotherapy

BTAS

Multi-site CMH Pilot Study

• Pathstone Mental Health (2 CFTs = 20 clients)

• HN REACH (2CFTs = 20 clients)

• Hamilton Health Services (2CFTs = 20 clients)

• Recruitment of 2 other CMHO agencies (40)

Session

#1

Session

#2

Session

#3

Session

#4

Baseline

AssessmentEndpoint

Assessment

• Demographics

•Pre measurement

•MASC2

•Parent/Youth forms

•Post measurement

•MASC2

•Parent/Youth forms

Questions?